From the Guidelines
For this patient with bilateral inguinal rash, suspected lichen sclerosus, and premature ejaculation, I recommend adding a potent topical corticosteroid such as clobetasol propionate 0.05% ointment to be applied thinly to the affected areas once daily for 2-4 weeks, then tapering to twice weekly maintenance if improvement occurs. The patient's current treatment with Lotrisone cream for one month is a good initial approach, but it may not be sufficient for lichen sclerosus, and the addition of a potent topical corticosteroid could enhance treatment efficacy 1. For premature ejaculation, Benzocaine Gel 7.5% is a reasonable treatment option, as recommended by the AUA/SMSNA guideline, which suggests daily SSRIs, on-demand clomipramine or dapoxetine, and topical penile anesthetics as first-line agents of choice in treatment of premature ejaculation 1. Additionally, the patient might benefit from behavioral techniques like the stop-start method or squeeze technique, as well as pelvic floor exercises and mindfulness practices to enhance the effectiveness of treatment. If symptoms persist after one month, referral to dermatology for biopsy confirmation of lichen sclerosus would be warranted before proceeding with circumcision, as early treatment with appropriate corticosteroids can prevent progression of fibrosis and potential complications. Some key points to consider in the treatment of premature ejaculation include:
- Daily SSRIs, such as paroxetine, sertraline, fluoxetine, and citalopram, can be effective in delaying ejaculation 1
- On-demand administration of clomipramine, paroxetine, sertraline, and fluoxetine can also be effective, but may be associated with less ejaculatory delay than daily treatment 1
- Topical penile anesthetics, such as benzocaine, can be used to treat premature ejaculation, but may be associated with numbness or decreased sensation 1. It is essential to weigh the potential benefits and risks of each treatment option and to consider the patient's individual needs and preferences when developing a treatment plan.
From the Research
Patient Assessment and Treatment
- The patient's physical exam revealed a bilateral inguinal rash and foreskin fibrosis with fibrosis of the glans, suggesting a possibility of lichen sclerosis 2, 3.
- The patient was prescribed Lotrisone cream for one month, and alternative treatment options, including circumcision, were discussed if no improvement is seen.
- For premature ejaculation, Benzocaine Gel 7.5% was recommended.
Treatment Considerations
- The use of combination topical clotrimazole-betamethasone dipropionate, such as Lotrisone, has been a topic of concern due to its potential for inadequate clearance or exacerbation of fungal infections, as well as cutaneous atrophy and other skin maladies 2, 3.
- Alternative treatments for rashes, such as referring to dermatologists, have been recommended to avoid the potential risks associated with high-potency topical corticosteroids 3.
Patient-Centered Care
- The biopsychosocial model can be used to guide patient-centered neurological treatments, considering biological, psychological, and social-cultural-spiritual factors impacting health and longitudinal care 4.
- Structured patient assessment frameworks can improve clinician performance of patient assessment and hold the potential to improve patient care and outcomes 5.
- Patient understanding of their treatment plan is crucial, and factors such as empathy, quality of communication, and patient-physician relationship can impact patient satisfaction and knowledge of their diagnoses and treatment plan 6.